A case of dizziness that turned out to be……………..

I was doing my rotation in the cardiology ward during residency. Once I was given an emergency call by the professor from the angiography room while doing angiography of a patient who developed sudden seizure on the operating table. In ran and found a young man having fits. It was the courtesy of cardiology professor to let me in as I was a resident coming from a medical ward and she wanted me to prepare this case for presentation in the Arag auditorium (Dow Medical College) in the following week. I managed him by giving 10 mg of inj. Valium intravenously which stopped the seizure. Later that patient was shifted in the ICU and later, I took the history. He was 30 years old man with no comorbid or any addiction.  He complained of malaise, weakness and continuously feeling dizzy with occasional blackouts since 6 months. His vision was also diminished in the past one year.

When I examined him, to my extreme surprise I found no radial pulse on both sides. His other physical exam was unremarkable. I investigated him,  and found normal hemoglobin level with normal cell indices. His echocardiogram was normal. His chemical panels were also normal. His ultrasound of abdomen was normal. Only abnormality was his raised ESR, 90 mm/1st hour.

Then I enquired about his angiography report that was performed a day before (during which he developed a seizure). It was a carotid artery angiogram. It showed significant narrowing of the branches of the carotid artery bilaterally with occlusions and dilatations throughout their courses entering the brain. 

So a diagnosis of a rare disease was made, that was Takayasu’s arteritis that is the granulomatous inflammation (vasculitis) of the branches of aorta. Although it mostly affects young females but in our case, a young male was affected.

We put him on oral steroids (1 mg/kg for 1 month) and asked for regular follow-ups for tapering the dose over several months to 10 mg daily. Takayasu arteritis is a chronic relapsing and remitting disease and needs a long term follow up.

So I presented this case in Arag auditorium on behalf of cardiology department where I was doing my one month rotation as part of my residency in medicine. Here, weekly case discussions were scheduled and this case was appreciated by all the professors and seniors. 

A doctor in a lifetime may never come across a patient with absent radial pulses! After seeing this patient, I never forget to palpate the pulses and to compare with the opposite  side!

Dr. Zeba Hisam

March, 2010